Pitted Keratolysis and its treatment in Homoeopathy:case Report

Dr Deeraj Ignacious Fernandes 

Abstarct- A case of a Male patient aged 29 years, came with pitted keratosis of left heel with the symptoms of circular pits, profuse  foul perspiration in the foot, the coldness of the foot

Keywords :pitted keratolysis,Silicea

Abbrevations :OPD-outpatient department, PK-Pitted keratolysis.

Introduction: Pitted keratolysis is a common disorder of skin that effects the stratum corneum of the plantar surface and is caused by gram positive bacteria that may show filamentous and coccoid structures. Pitted Keratolysis (PK) also known as keratolysis plantare sulcatum.

Causative organism-kytococcus(formerly known as micrococcus)sedentarius Corynebacterium¹,Other bacterias like dermatophilus congolensis  and micrococcus sedentarius also play a major role. These bacteria produce and excrete exoenzymes (keratinase) that are able to degrade keratin and produce pitting in the stratum corneum when the skin is hydrated and the ph rises above neutrality⁴ 

Predisposing factors-environmmental factors like geographically a tropical location ,summer season,occlusive foot wear and wet work.patient factors like plantar  hyperhidrosis and plantar keratoderma.

There will be numerous superficial circular pits with a punched out appearance on the soles,the instep will be usually spared². Commonly it is been seen in domwstic servants ,hotel boys, sharbat vendors,seamen and occassionall\y housewives are affected³.

Pitted keratolysis is a disease mimicking tinea pedis,rarely been seen in non pressure bearing locations. Most of the times it is asymptomatic but painful and plaquelike lesions will occur both in adults and children.

Plantar sulcatum or pitted keratolysis can be diagnosed clinically,causative organism can be identified  from the pitted lesions and cultured on brain heart infusion agar. Skin biopsy can be done in some cases which will reveal the characteristic histopathological features of pitted keratolysis.

CASE STUDY
A 29 year old male ,salesman by occupation, came to visit on 23 november 2019, with the complaint of pitted keratolysis in his left heel,since 6 to 8 months with skin pittings in the heel, excessive sweating and coldness of the foot. There is also fowl smell if he is wearing shoes for a longer period of time.

This skin condition started since 6 to 8 months , he has not taken any treatment and for the first time he came to homoeopathy.

Location	sensation	Modality	concomitant
Left Leg Heel Since 6-8 months	Pitting of the skin2 Excessive sweating in heels3 Fowl odour3 Coldness of the feet3	< sweating3 < walking for a long time <wearing shoes2	Nothing particular

There was no prominent past history.

Family history

Father -Has diabetes mellitus since 15 years

Physical generals- The patients appetite, thirst and bladder were normal. Perspiration was profuse on scalp, palms and soles. Patient suffers from hard stools since childhood. Patient wanted to cover always  and he used to dislike winter. Patient has a strong dislike towards cold food

Mental Generals
According to patient he says that he is obstinate¹⁰ person since childhood, he always stands by his wish and will and will never agree for others opinion. Since his childhood also he never used to participate in any extra curricular activities due to his shyness.

Life space investigation
Patient belongs to a middle socio economic class family, his dad was a teacher and mom was a housewife. He has a younger sister, he was not at all interested in studies so discontinued after 11 ^th standard and started working in a hotel. He wanted to start a mobile repair shop, though his parents wanted him to study he was very much adamant about his dream. Presently he is working as a sales man in a electronics shop, but he feels he unable to convince customers due to lack of courage. Each time a new customer comes to the shop, he has a feel of hesitation to approach them, gets embarrassed easily.

Diagnosis Analysis

1.clinical diagnosis- Pitted keratolysis

2.ICD-10-CM classification code L08.89⁵

3.Reasoning:

      a. The infection is characterised by craterlike pits on the surface of the feet and toes.

      b. The infection caused by wearing tight or restricting footwear and due to excessive sweating.

     Differential diagnosis

1. Tenia pedis
2. Keratolysis exfoliative

Symptom	Type	Intensity (on a scale of 1 to 3
Obstinate	Characteristic mental symptom	3
Shyness	Characteristic mental symptom	3
Perspiration -fowl smell	Characteristic physical general symptom	3
Perspiration – foot	Characteristic physical general symptom	3
Aggravation for cold food	Characteristic physical general symptom	3
Coldness of foot	Characteristic physical general symptom	3

RUBRICS CHOSEN AFTER CASE ANALYSIS

1. Mind -obstinate
2. Mind- timidity
3. Perspiration -fetid odour
4. Extremities-foot-perspiration
5. Extremities -coldness of foot
6. Generals -food and drinks-cold food aggravation

REPERTORISATION⁶ 

Repertory sheet is been attached below

Remedy analysis and discussion

After repertorisation , the main remedies that could be considered included SILICEA (18/6), PULSATILLA(16/6),LYCOPODIUM(15/6). Both lycopodium and pulsatilla are hot remedies. Pulsatilla was a closely covering remedy, as most of the symptoms of the patient were covered by silicea like “ obstinacy”, “ coldness of feet¹²”, “ fetid perspiration”.

REMEDY REASONING
Silicea  covered all then mental symptoms as well as the physical symptoms of the partient. Obstinacy was one of the core mental symptom of the patient. Because of his obstinate behaviour he discontinued his studies.

Silecea patient has marked timidity¹³, the patient because of his shyness is not able to communicate to his customers , gets embarrassed¹¹.

Physical generals like perspiration has a fowl odour¹⁵ and it is seen increased in foot¹⁴.Ailments caused by suppressed foot sweat⁹

Prescription: Silicea  200 ( 1 packet) was given for a period of one  month along with no 40 pills 4-0-4..

These are the main characteristic symptoms that led to select the remedy

1. Obstinate
2. Timidity 
3. Perspiration – increased in foot
4. Perspiration- fetid odour
5. Coldness of the foot
6. Cold food aggravation

 200(high) potency  was chosen because the more similar the remedy, the greater the susceptibility to that remedy, the higher the potency required⁷.

The case was a clinical diagnosed case of pitted keratosis with pitting of the skin in the left heel, with fowl perspiration and coldness of the foot. Silecea 200 was prescribed for a period of 2 months, where the patient had visited once for a follow up and as the patient was better  SAL LAC was been given.

Date	Follow-up	Remedy given	Reason
20/12/2019	Patients pitting eruptions present on the heel is better	SAC LAC	Since the action of the remedy previously given continuing and no new symptoms were present8
25/1/2020	Pitting eruptions present on the heel is 90 percentage better	SAC LAC	As the patient is better with the symptoms, saclac was given

BEFORE

AFTER

CONCLUSION

Difficulties encountered during the case:

1. Only PQRS symptoms were considered while repertorising as well as while prescribing the remedy.
2. Patient was not that cooperative so it was difficult to get more mind symptoms.

Considering only PQRS symptoms with careful prescription and observation will end up in a positive result.

References

1. KHANNA, N. (2019). ILLUSTRATED SYNOPSIS OF DERMATOLOGY & SEXUALLY TRANSMITTED DISEASES. 5th ed. [S.l.]: ELSEVIER INDIA, pp.257-58.
2. Valia, R. (1994). Textbook and atlas of dermatology. Bombay: Bhalani, p.48.
3. Khopkar, U. (2009). Skin Diseases and sexually transmitted infections. 6th ed. Mumbai: Bhalani publishers, p.42.
4. Habif, T. (n.d.). Clinical dermatology. 4th ed. UK: Elsevier, pp.498-501.
5. ICD-10 Version:2010. Available from : http://icd.who.int/browse10/2010/en L08.89
6. RADAR Software
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11. Kent J. Lectures on Materia Medica. 1st ed. New Delhi: B.Jain Publishers; 1994.
12. Clarke. A Dictionary of practical Materia Medica. 1st ed. New Delhi: B.Jain Publishers; 1996.
13. Kent J. Repertorty of the Homoeopathic Materia Medica. 6th ed. New Delhi: B.Jain Publishers (P) LTD; 2009.
14. Murphy R. Homoeopathic Medical Repertory. 3rd ed. New Delhi: B.Jain publishers (P) Ltd; 2013.
15. Phatak S. A consise Repertory of Homoeopathic Medicines. 1st ed. New Delhi: B.Jain Publishers(P) Ltd; 2001.

Dr. Deeraj Ignacious Fernandes BHMS,MD
Assistant Professor.
Department of Organon of Medicine.
Father Muller Homoeopathic Medical college hospital, Deralakatte mangalore.